Failure to Provide Bed Hold Notices and Notify LTC Ombudsman During Transfers and Discharges
Penalty
Summary
The facility failed to provide required written notices of bed hold policies to residents or their representatives at the time of hospital transfers, and did not send notifications of transfers or discharges to the Office of the State LTC Ombudsman for four residents reviewed for the discharge process. Specifically, for two residents who were transferred to the hospital, there was no documentation that either the residents or their representatives received information about the bed hold policy, nor were they contacted during the hospital stay to discuss the option of holding the resident's bed. Interviews confirmed that neither the residents nor their representatives recalled receiving such notifications or being informed about the possibility of bed holds. Additionally, for two other residents who were discharged, there was no documentation that the LTC Ombudsman was notified of their discharge, as required. Staff interviews revealed that the facility's process for notifying the Ombudsman had lapsed, with the current medical records staff unaware of the requirement to send such notifications since taking their position. The administrator acknowledged that the facility had not been sending out these notifications as required. Facility staff also indicated a misunderstanding of the requirements, believing that providing a bed hold policy in the transfer packet or automatically holding beds for Medicaid residents was sufficient to meet regulatory obligations. However, there was no evidence of individualized follow-up or confirmation that residents or their representatives were informed of their rights or the specifics of the bed hold policy at the time of transfer or discharge.